2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients.

In view of the increasing complexity of both cardiovascular implantable electronic devices (CIEDs) and patients in the current era, practice guidelines, by necessity, have become increasingly specific. This document is an expert consensus statement that has been developed to update and further delineate indications and management of CIEDs in pediatric patients, defined as ≤21 years of age, and is intended to focus primarily on the indications for CIEDs in the setting of specific disease categories. The document also highlights variations between previously published adult and pediatric CIED recommendations and provides rationale for underlying important differences. The document addresses some of the deterrents to CIED access in low- and middle-income countries and strategies to circumvent them. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by class of recommendation and level of evidence. Several questions addressed in this document either do not lend themselves to clinical trials or are rare disease entities, and in these instances recommendations are based on consensus expert opinion. Furthermore, specific recommendations, even when supported by substantial data, do not replace the need for clinical judgment and patient-specific decision-making. The recommendations were opened for public comment to Pediatric and Congenital Electrophysiology Society (PACES) members and underwent external review by the scientific and clinical document committee of the Heart Rhythm Society (HRS), the science advisory and coordinating committee of the American Heart Association (AHA), the American College of Cardiology (ACC), and the Association for European Paediatric and Congenital Cardiology (AEPC). The document received endorsement by all the collaborators and the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). This document is expected to provide support for clinicians and patients to allow for appropriate CIED use, appropriate CIED management, and appropriate CIED follow-up in pediatric patients.

X-ray management in electrophysiology: a survey of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC).

AIMS: Radiation use in medicine has significantly increased over the last decade, and cardiologists are among the specialists most responsible for X-ray exposure. The present study investigates a broad range of aspects, from specific European Union directives to general practical principles, related to radiation management among a national cohort of cardiologists. METHODS AND RESULTS: A voluntary 31-question survey was run on the Italian Arrhythmology and Pacing Society (AIAC) website. From June 2019 to January 2020, 125 cardiologists, routinely performing interventional electrophysiology, participated in the survey. Eighty-seven (70.2%) participants are aware of the recent European Directive (Euratom 2013/59), although only 35 (28.2%) declare to have read the document in detail. Ninety-six (77.4%) participants register the dose delivered to the patient in each procedure, in 66.1% of the cases both as fluoroscopy time and dose area product. Years of exposition (P = 0.009) and working in centers performing pediatric procedures (P = 0.021) related to greater degree of X-ray equipment optimization. The majority of participants (72, 58.1%) did not recently attend radioprotection courses. The latter is related to increased awareness of techniques to reduce radiation exposure (96% vs. 81%, P = 0.022), registration of the delivered dose in each procedure (92% vs. 67%, P = 0.009), and X-ray equipment optimization (50% vs. 36%, P = 0.006). CONCLUSION: Italian interventional cardiologists show an acceptable level of radiation awareness and knowledge of updated European directives. However, there is clear space for improvement. Comparison to other health professionals, both at national and international levels, is needed to pursue proper X-ray management and protect public health.

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias.

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

Cardiac surgeon and electrophysiologist shoulder-to-shoulder approach: Hybrid room, a kingdom for two. A zero mortality transvenous lead extraction single center experience.

BACKGROUND: Nowadays, transvenous lead extraction (TLE) is considered an essential technique in lead management strategy. Since 2011, a multidisciplinary approach was undertaken in our centre involving electrophysiologists, cardiac surgeons and anaesthesiologists to improve cross- unit cooperation and minimize complications and mortality. The present paper reports procedural outcomes and complications of our lead extraction experience. METHODS: We retrospectively collected and analysed data from all consecutive patients undergoing cardiac implantable electronic device leads TLE at the IRCCS Centro Cardiologico Monzino between January 2011 and November 2017. RESULTS: One-hundred fifty patients (111 males, 68 ±â€¯13 years) underwent extraction procedures. The most common extraction indication were infections (86.7%) and TLE was carried out by laser-based approach in 88 (58.6%) patients, by mechanical dilating sheaths in 58 (38.7%) patients and by a combined approach (TLE + open surgical intervention) in 4 (2.7%) patients. Procedural success was obtained in 146 (97.3%) cases with only 3 (2.0%) major complications with 2 cases of structural injury with tamponade requiring emergent median sternotomy. Open surgery extraction was required in 4 patients, after an attempt to TLE, due to leads strict adhesion to cardiac or vascular structures, whereas in 5 (3.3%) cases, the treatment of choice was a combined approach consisting in transvenous leads extraction followed by planned surgery. CONCLUSIONS: TLE is a complex procedure that sometimes leads to fatal complications. In our single center experience, a multidisciplinary approach involving electrophysiologist, cardiac surgeon, anaesthesiologist in an operating room allows a safer approach and major complications treatment.

QT interval variability in body surface ECG: measurement, physiological basis, and clinical value: position statement and consensus guidance endorsed by the European Heart Rhythm Association jointly with the ESC Working Group on Cardiac Cellular Electrophysiology.

This consensus guideline discusses the electrocardiographic phenomenon of beat-to-beat QT interval variability (QTV) on surface electrocardiograms. The text covers measurement principles, physiological basis, and clinical value of QTV. Technical considerations include QT interval measurement and the relation between QTV and heart rate variability. Research frontiers of QTV include understanding of QTV physiology, systematic evaluation of the link between QTV and direct measures of neural activity, modelling of the QTV dependence on the variability of other physiological variables, distinction between QTV and general T wave shape variability, and assessing of the QTV utility for guiding therapy. Increased QTV appears to be a risk marker of arrhythmic and cardiovascular death. It remains to be established whether it can guide therapy alone or in combination with other risk factors. QT interval variability has a possible role in non-invasive assessment of tonic sympathetic activity.

Opportunities and challenges of current electrophysiology research: a plea to establish 'translational electrophysiology' curricula.

Cardiac electrophysiology has evolved into an important subspecialty in cardiovascular medicine. This is in part due to the significant advances made in our understanding and treatment of heart rhythm disorders following more than a century of scientific discoveries and research. More recently, the rapid development of technology in cellular electrophysiology, molecular biology, genetics, computer modelling, and imaging have led to the exponential growth of knowledge in basic cardiac electrophysiology. The paradigm of evidence-based medicine has led to a more comprehensive decision-making process and most likely to improved outcomes in many patients. However, implementing relevant basic research knowledge in a system of evidence-based medicine appears to be challenging. Furthermore, the current economic climate and the restricted nature of research funding call for improved efficiency of translation from basic discoveries to healthcare delivery. Here, we aim to (i) appraise the broad challenges of translational research in cardiac electrophysiology, (ii) highlight the need for improved strategies in the training of translational electrophysiologists, and (iii) discuss steps towards building a favourable translational research environment and culture.

[Changes of QT interval during graded exercise test in healthy adolescents aged 11-15 years].

Aim of the study was determination of physiological limits of QT-intervals and its derivative values in healthy children and adolescents during graded exercise tests. We examined 100 healthy boys and girls aged 11-15 years (mean age 13.4+/-2.1 years) and performed electrocardiography at rest and standard veloergometry (VEM) in all of them. We analyzed corrected intervals according to Bazett (QTc=QT/RR) and Fredericia (FQTc/3RR) formulas. Hysteresis QTc was calculated as difference between QTc durations during recovery and exercise at same heart rate (HR) Baseline HR before VEM exceeded rhythm on resting electrocardiogram by 5-15 bpm (84+/-8 vs 70+/-6, respectively, p<0.05) Increase of HR at exercise (mean 172+/-11 bpm) was similar in both sexes. QT interval decreased by 7-10% (18-31 ms) per each 25 w (p<0.05). Values obtained at determination of FQTc we found values 26-52 ms lower than those calculated by the Bazett formula in the process of whole test. Determination of FQTc compared with calculation by Bazett formula revealed more pronounced (10% from baseline level) shortening of FQT at peak exercise. QT calculated by the Bazett formula at 100 w did not differ from baseline level with tendency to higher level. Corrected QT according to the most often used Bazett formula was maximal at the first stage of exercise (25 w) and did not exceed 450 ms in boys and 460ms in girls. Maximal QTc lengthening in the process of test did not exceed 50 ms in any of the examined persons. Hysteresis of QTc interval was equal to 21+/-6 (15-25) ms. The conclusion was made that algorithm of assessment of QT interval changes during exercise test should include initial values of QTc calculated according to the Bazett formula, maximal QTc value, level of exercise at which it was registered, maximal increase of QTc during exercise, and QTc interval hysteresis.

Core curriculum for the heart rhythm specialist: executive summary.

Heart rhythm (HR) management is rapidly developing as a subspecialty within cardiology, and it is imperative to promote and ensure sufficient and homogeneous training and qualification amongst professionals in Europe. This has led the European Society of Cardiology, through the European Heart Rhythm Association (EHRA), to organize a European Core Curriculum for the HR specialist through the following: definition of the scope of the HR speciality (Syllabus), development of minimum standards and objectives for training in HR management (Curriculum), development of a model to certify HR professionals and teaching units (Accreditation), and development of a Registry for European HR accredited professionals and teaching units and its activity (Registries). The duration of the training period should be of a minimum of 2 years following general cardiology training. During this period, the trainee must develop the required knowledge, practical skills, behaviours, and attitudes to manage HR patients. The trainee must be involved in a minimum number of different procedures and achieve specified levels of competence. The training centre should be integrated within a full-service cardiology department. Assessment of the trainee and the training programmes should include reports by the training programme supervisor and the national society HR organizations, a logbook of procedures, written examinations, and assessment of professionalism. The EHRA presently requires the trainee to pass the EHRA accreditation exams (invasive EP and cardiac pacing and ICDs). Continuous learning and practice are required to maintain standards and practice and because substantial changes may occur in clinical practice or the health-care environment.

Airway interventions in the cardiac electrophysiology laboratory: a retrospective review.

OBJECTIVE: To quantify the incidence of airway interventions during cardiac electrophysiology laboratory procedures. DESIGN: A retrospective chart review. SETTING: A tertiary care teaching hospital. PARTICIPANTS: Two-hundred eight adult patients undergoing cardiac electrophysiology laboratory procedures during a 2-year period, March 2006 to March 2008. The patients underwent the following procedures: supraventricular tachycardia ablation, atrial tachycardia ablation, atrial flutter ablation, premature ventricular contraction ablation, and ventricular tachycardia ablation. Patients who were intubated (in the intensive care unit or emergency department) before the ablation began, patients with ventricular assist devices or intra-aortic balloon pumps, and patients receiving inotropic support before the procedure were excluded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The data were summarized by using the mean and standard deviation. Of the 208 patients, 186 were planned monitored anesthesia care, and 22 were planned general anesthetics. Of the monitored anesthesia care cases, 20 were converted to general anesthesia, and 54 received some type of airway intervention including oral-pharyngeal airway or nasal airway insertion. Therefore, 40% (74/186) of the non-general anesthesia cases required an airway intervention. CONCLUSIONS: These results suggest that a significant proportion of the authors' patients undergoing cardiac electrophysiology laboratory procedures required deep sedation if not general anesthesia, although a non-general anesthetic was planned. The issue of depth of sedation has implications for patient safety, privileging, and regulatory compliance. Based on the present results, the authors believe sedation for these procedures is best given by anesthesia providers; furthermore, caregivers should be aware that these procedures are likely to require deep sedation if not general anesthesia.